Evaluation of Pharmacist-led Medication Reconciliation Service Benefits in Hospitalised Medical Patients

Impact of Routine Pharmacist-led Medication Reconciliation on Medication Discrepancies and Post-hospital Healthcare Utilisation

Background:

Transitions of care often lead to medication errors and unnecessary healthcare utilisation. It has been repeatedly shown that medication reconciliation can at least partially reduce this risk.

Objective:

The aim of this prospective pragmatic trial was to evaluate the effectiveness of pharmacist-led medication reconciliation offered to medical patients as part of routine clinical practise.

The main questions to be answered were:

• the effectiveness of pharmacist-led medication reconciliation on medication discrepancies at discharge and 30 days after discharge
• the effectiveness of pharmacist-led medication reconciliation on healthcare utilisation within 30 days after discharge.

Participants in the intervention group were offered the following:

• medication reconciliation on admission
• medication reconciliation on discharge, coupled with patient counselling, provided by clinical pharmacists.

Participants in the control group were offered standard care.

Design: pragmatic, prospective, controlled clinical trial

Setting: Five general medical wards at the University Clinic of Respiratory and Allergic Diseases in Slovenia:

• one intervention ward with a routine pharmacist-led medication reconciliation service
• four control wards

Data collection:

• Data collection and outcome assessment were performed by research pharmacists who were clinical pharmacists or final year clinical pharmacy residents not involved in the treatment of the included patients.
• Data for the assessment of medication errors at discharge were obtained from the patients' medical records and the study documentation.
• The reason for the patient's hospitalisation was obtained from the discharge letter and divided into acute or planned admissions. The main diagnosis was the reason for admission, while all other patient diagnoses listed were used to assess comorbidity.
• Patient comorbidity was assessed using the Charlson Comorbidity Index
• For patients in the control group the BPMH was collected in the same way as in the intervention group. However, it was only used for study purposes and was not documented in the patients' medical records
• Data on healthcare utilisation and medication discrepancies after hospital discharge were collected through patients or caregivers' phone interview.

Inclusion Criteria:

• All adult medical patients admitted to the study wards

Exclusion Criteria:

• patients who do not speak Slovenian,
• transferred from another ward,
• previously included in the same study.

Subsequent exclusion from the analysis:

• patients hospitalised only for diagnostic purposes,
• patients transferred to another ward or hospital,
• patients that died during hospitalisation,
• patients from the control group who were offered medication reconciliation